<!DOCTYPE html>
<html lang="en">
<head>

<meta charset="utf-8">
<meta name="description" content="Miminium Admin Template v.1">
<meta name="author" content="Isna Nur Azis">
<meta name="keyword" content="">
<meta name="viewport" content="width=device-width, initial-scale=1">
<title>油乐宝分销系统</title>

<!-- start: Css -->
<link rel="stylesheet" type="text/css" href="__PUBLIC__/asset/css/bootstrap.min.css">

<!-- plugins -->
<link rel="stylesheet" type="text/css" href="__PUBLIC__/asset/css/plugins/font-awesome.min.css"/>
<link rel="stylesheet" type="text/css" href="__PUBLIC__/asset/css/plugins/simple-line-icons.css"/>
<link rel="stylesheet" type="text/css" href="__PUBLIC__/asset/css/plugins/mediaelementplayer.css"/>
<link rel="stylesheet" type="text/css" href="__PUBLIC__/asset/css/plugins/animate.min.css"/>
<link rel="stylesheet" type="text/css" href="__PUBLIC__/asset/css/plugins/icheck/skins/flat/red.css"/>
<link href="__PUBLIC__/asset/css/style.css" rel="stylesheet">
<!-- end: Css -->

<link rel="shortcut icon" href="__PUBLIC__/asset/img/logomi.png">
<!-- HTML5 shim and Respond.js IE8 support of HTML5 elements and media queries -->
  <!--[if lt IE 9]>
    <script src="https://oss.maxcdn.com/html5shiv/3.7.2/html5shiv.min.js"></script>
    <script src="https://oss.maxcdn.com/respond/1.4.2/respond.min.js"></script>
    <![endif]-->
  </head>


<body id="mimin" class="dashboard">
      <!-- start: Header -->
      {include file="public/head" /}
      <!-- end: Header -->

      <div class="container-fluid mimin-wrapper">
  
          <!-- start:Left Menu -->
          {include file="public/left" /}
          <!-- end: Left Menu -->


          <!-- start: Content -->
          <div id="content">
                <div class="panel box-shadow-none content-header">
                  <div class="panel-body">
                    <div class="col-md-12">
                        <h3 class="animated fadeInLeft">账单 设置</h3>
                        <p class="animated fadeInDown">
                          首页 <span class="fa-angle-right fa"></span>提现 申请
                        </p>
                    </div>
                  </div>
                </div>
                <div class="form-element">
                <div class="col-md-12 padding-0">
                
                <div class="col-md-10">
                  <div class="col-md-12 panel">
                    <div class="col-md-12 panel-heading">
                      <h4>充值 申请</h4>
                    </div>
                    <div class="col-md-12 panel-body" style="padding-bottom:30px;">
                      <div class="col-md-12">
                        <form class="cmxform" id="signupForm" method="post" action="{:Url('bill/payApplyForm')}">
                          <div class="col-md-6">
                            

                              <div class="form-group"><label class="col-sm-2 control-label text-right">充值方式</label>
                              <div class="col-sm-10" >
                                <div class="col-sm-12 col-md-2 padding-0" >
                                  <input type="radio" name="payWay" value = "1" id = "AliPay" checked="checked" > 支付宝
                                </div>
                                <div class="col-sm-12 col-md-2 padding-0">
                                  <input type="radio" name="payWay" value = "2" id = "WeChatPay "> 微信
                                </div>
                                <div class="col-sm-12 col-md-2 padding-0">
                                  <input type="radio" name="payWay" value = "3" id = "BankPay"> 打款
                                </div>
                              </div>
                            </div>
                            
                            <div class="form-group form-animate-text" style="margin-top:40px !important;">
                               <input type="text" class="form-text" name="pay_name" required>
                               <span class="bar"></span>
                               <label>充值 姓名</label>
                             </div>
                            
                            <div class="form-group form-animate-text" style="margin-top:40px !important;">
                              <input type="text" class="form-text" name="pay_reason" required>
                              <span class="bar"></span>
                              <label>充值 理由</label>
                            </div>
                            <div class="form-group form-animate-text" style="margin-top:40px !important;">
                              <input type="text" class="form-text" name="pay_description" required>
                              <span class="bar"></span>
                              <label>充值 描述</label>
                            </div>
                            

                            <div class="form-group form-animate-text" style="margin-top:40px !important;">
                              <input type="text" class="form-text"  name="pay_money" required>
                              <span class="bar"></span>
                              <label>充值 金额</label>
                            </div>

                            

                          </div>                   
                          <div class="col-md-12">                              
                              <input class="submit btn btn-danger" type="submit" value="提交">
                        </div>
                      </form>

                    </div>
                  </div>
                </div>
              </div>
              </div>
              </div>
            </div>
          <!-- end: content -->
          
      </div>

      <!-- start: Mobile -->
      {include file="public/mobile" /}
       <!-- end: Mobile -->

<!-- start: Javascript -->
<script src="__PUBLIC__/asset/js/jquery.min.js"></script>
<script src="__PUBLIC__/asset/js/jquery.ui.min.js"></script>
<script src="__PUBLIC__/asset/js/bootstrap.min.js"></script>


<!-- plugins -->
<script src="__PUBLIC__/asset/js/plugins/moment.min.js"></script>
<script src="__PUBLIC__/asset/js/plugins/icheck.min.js"></script>
<script src="__PUBLIC__/asset/js/plugins/jquery.nicescroll.js"></script>


<!-- custom -->
<script src="__PUBLIC__/asset/js/main.js"></script>
<script type="text/javascript">
$(document).ready(function(){
     $('input').iCheck({
        checkboxClass: 'icheckbox_flat-red',
        radioClass: 'iradio_flat-red'
      });
});
</script>
<!-- end: Javascript -->
</body>
</html>